Inspection · 2023-05-04
Licensing Inspector
Danielle Morrison
(804) 929-3771
SHSIA monitoring inspection of an approved subsidy vendor to determine compliance with current subsidy requirements regarding the health and safety of children and to promote quality standards for the children in their care.
No
Areas Reviewed
8VAC20-780 Administration.
8VAC20-780 Staff Qualifications and Training.
8VAC20-780 Physical Plant.
8VAC20-780 Staffing and Supervision.
8VAC20-780 Programs.
8VAC20-780 Special Care Provisions and Emergencies.
8VAC20-780 Special Services.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
Inspector Notes
A renewal inspection was conducted on 5/4/2023 with center staff. There were 72 children present, ranging in ages from 5 years to 12 years, with 6 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. Staff records were shared electronically 5/5/2023. A total of 8 child records and 6 staff records were reviewed. The children were having afternoon snack, playing outdoors, doing homework, and having free play with games and manipulatives.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program.
Time of today?s inspection: 3:50 p.m. to 5:50 p.m.
Please call me if you have any questions at 804-381-8487 or e-mail tara.barton@doe.virginia.gov.
Standard 22.1-289.035-B-2
Based on review of six staff records, the facility failed to obtain a fingerprint based national criminal check prior to employment for each staff as required. Evidence: Staff 2 (date of employment 10/14/2020) did not have a fingerprint result on file until 11/2/2020.
Plan of Correction: Staff will not work in the licensed programs until eligible fingerprint results are obtained.
Standard 8VAC20-780-160-C
Based on a review of six staff records, the facility failed to have a repeat tuberculosis (TB) test or screening at least every two years from the date of the initial screening. Evidence: Staff 2 had a tuberculosis test that expired 11/13/2022.
Plan of Correction: Staff 2 will get a repeat TB test or screening.
Standard 8VAC20-780-190-A
Based on review of one staff file and discussion with management, the center failed to have a qualified program director. Evidence: Staff 1 is identified as the program director (date of promotion 8/2022). There is no documentation to support that Staff 1 meets the qualification of program director.
Plan of Correction: A different staff person who meets qualifications will be designated as program director. Staff 1 will work to meet qualifications.
Standard 8VAC20-780-350-B-5
Based on observation and staff interview, the facility failed to maintain the required ratio of one staff for every 18 children ages "school age eligible" to 9 years. Evidence: on 5/4/2023, Staff 2 was alone with 22 children, ages 8 through 10 years. Staff 2 stated "I thought I had 17 children". Staff 1 stated that one of the staff called out today.
Plan of Correction: Classrooms will maintain the required ratios.
Standard 8VAC20-780-530-A-1
Based on staff interview and record review, the facility failed to have one staff in each grouping of children with cardiopulmonary resuscitation (CPR) certification. Evidence: Staff 2 was alone with 22 school age children, but did not have documentation of current CPR certification on file. Management confirmed that CPR expired 3/11/2023. Staff 4 was alone with 12 school age children, but did not have documentation of current CPR on file. Management confirmed that CPR expired 12/17/2022.
Plan of Correction: Staff will get updated first aid and CPR.
Standard 8VAC20-780-530-A-2
Based on staff interview and record review, the facility failed to have one staff in each grouping of children with first aid certification. Evidence: Staff 2 was alone with 22 school age children, but did not have documentation of current first aid certification on file. Management confirmed that first aid certification expired 3/11/2023. Staff 4 was alone with 12 school age children, but did not have documentation of current first aid on file. Management confirmed that first aid certification expired 12/17/2022.
Plan of Correction: Staff will get updated first aid and CPR.
Standard 8VAC20-780-60-A
Based on review of eight children's files, the facility failed to have required information in each child's file. Evidence: Child 1, Child 2, and Child 4 did not have documentation of the name, address, and phone number of two (non-parent) designated people to contact in an emergency if a parent cannot be reached. Child 3 only had one (non-parent) emergency contact name, address, and phone number listed. Child 4 did not have the name and phone number of the parent's employment.
Plan of Correction: Parents will be asked to provide necessary information.
Standard 8VAC20-780-70
Based on review of six staff records, the facility failed to have required documentation in each file. Two references as to character, reputation, and competence should be checked prior to employment. Evidence: Staff 2 (date of employment 10/14/2020) did not have documentation of two references on file.
Plan of Correction: Missing information will be requested.